Thyroid Storm

Audience This is a practice oral boards case which may be given to emergency medicine (EM) residents at all levels of training and recent EM graduates. Introduction/Background Thyroid storm is an acute, life-threatening endocrine emergency. It occurs when there is excess circulating thyroid hormone in the bloodstream. It may be precipitated by infection, surgery, pregnancy, trauma, thyroid medication changes, or iodinated contrast exposure. This condition must be quickly identified and treated by EM physicians in order to prevent morbidity and mortality. IThe mortality rate is between 10 and 30%1 Understanding and treating thyroid storm is included in the 2019 Model of Clinical Practice of Emergency Medicine.2 Educational Objectives At the end of this practice oral boards case, the learner will: 1) assess a patient with altered mental status in an oral boards format; 2) review appropriate laboratory testing and diagnostic imaging; 3) identify signs and symptoms of thyroid storm and 4) review appropriate pharmacologic therapies with the proper sequence and timing. Educational Methods Practice boards case. Research Methods This oral boards practice case was developed and then tested in several small group settings. First, EM resident learners discussed the case in a small group format. Their feedback was utilized to refine the case’s textual information. Subsequently, EM physicians preparing for the ABEM oral board examination provided additional general feedback of the case and completed an anonymous survey regarding case quality and educational value. Results Minor changes were made based on feedback from small group sessions. The finalized case was tested with individuals, and surveys showed that 92% (12/13) of individuals rated the case quality as excellent (standard Likert scale 1–5 with 5 being Excellent). All participants responded affirmatively that the case enhanced their understanding of thyroid storm. Discussion This oral boards practice case was effective in preparing learners for the ABEM oral boards exam. Based on learner feedback, several laboratory results were added to the stimulus package and wording was edited to improve the clarity of the case. Topics Hyperthyroidism, thyrotoxicosis, thyroid storm, endocrine emergencies, altered mental status.


Linked objectives and methods:
inked objectives and methods:

An oral boards format was selected as an alternative modality to teach this core EM topic in order to provide real-time feedback to the learner as the case progresses.Symptoms of thyroid storm are often initially non-specific and may mimic many other clinical entities, making this teaching style beneficial because learners must form a large differential diagnosis and remember to suspect endocrine abnormalities as a possible cause (Objective 1).After initial evaluation, learners must then order, review, and interpret appropriate laboratory testing and diagnostic imaging with attention given to information which leads them to the ultimate diagnosis (Objective 2).Based on the information provided, learners should hone in on signs and symptoms which point to thyroid storm (Objective 3).After establishing thyroid storm as the appropriate diagnosis, learners should order appropriate pharmacologic interventions in the proper order for treatment (Objective 4).The use of a one-on-one practice case format enables the teacher to tailor additional information to various levels of training when providing further information on clinical pearls after the case conclusion.Any gaps in knowledge may be identified by the examiner and then addressed in a focused debrief or mini-lecture after the conclusion of the practice case.

Recommended pre-reading for instructor:

• Awad N.


Results and tips for successful implementa An oral boards format was selected as an alternative modality to teach this core EM topic in order to provide real-time feedback to the learner as the case progresses.Symptoms of thyroid storm are often initially non-specific and may mimic many other clinical entities, making this teaching style beneficial because learners must form a large differential diagnosis and remember to suspect endocrine abnormalities as a possible cause (Objective 1).After initial evaluation, learners must then order, review, and interpret appropriate laboratory testing and diagnostic imaging with attention given to information which leads them to the ultimate diagnosis (Objective 2).Based on the information provided, learners should hone in on signs and symptoms which point to thyroid storm (Objective 3).After establishing thyroid storm as the appropriate diagnosis, learners should order appropriate pharmacologic interventions in the proper order for treatment (Objective 4).The use of a one-on-one practice case format enables the teacher to tailor additional information to various levels of training when providing further information on clinical pearls after the case conclusion.Any gaps in knowledge may be identified by the examiner and then addressed in a focused debrief or mini-lecture after the conclusion of the practice case.
Recommended pre-reading for instructor: • Awad N.

Results and tips for successful implementation:
ion:

This case was designed to be used This case was designed to be used as preparation for the emergency medicine oral board examination.Faculty members may administer the case to residents by presenting the initial case information and then requesting for residents to verbalize their evaluation and clinical treatment plan.In addition, it may be used as part of a didactic teaching curriculum, which begins with the case presentation and then focuses on key teaching points as a mini-lecture following the case resolution.This oral boards case was developed and then previewed in small group settings to ensure inclusive information and to resolve any ambiguities of the case.The finalized version was then tested with thirteen physicians who were preparing for the ABEM oral boards and a survey was administered to assess case quality and educational value.92% (12/13) of these physicians rated the case as excellent (standard Likert scale 1-5 with 5 being Excellent), and all residents responded affirmatively that the case enhanced their understanding of thyroid storm.Learners noted that the case was "complex" and "allowed for higher order thinking," also stating that "there were subtle features that should clue the examinee not to anchor on sepsis" and that "it was helpful to think through the differential for a hyperthermic altered patient."Based on feedback from these sessions, additional learning points were clarified.
s preparati

for the emergency medicine oral board examinati
n.Faculty members may administer the case to residents by presenting the initial case information and then requesting for residents to verbalize their evaluation and clinical treatment plan.In addition, it may be used as part of a didactic teaching curriculum, which begins with the case presentation and then focuses on key teaching points as a mini-lecture following the case resolution.This oral boards case was developed and then previewed in small group settings to ensure inclusive information and to resolve any ambiguities of the case.The finalized version was then tested with thirteen physicians who were preparing for the ABEM oral boards and a survey was administered to assess case quality and educational value.92% (12/13) of these physicians rated the case as excellent (standard Likert scale 1-5 with 5 being Excellent), and all residents responded affirmatively that the case enhanced their understanding of thyroid storm.Learners noted that the case was "complex" and "allowed for higher order thinking," also stating that "there were subtle features that should clue the examinee not to anchor on sepsis" and that "it was helpful to think through the differential for a hyperthermic altered patient."Based on feedback from these sessions, additional learning points were clarified.

References/suggestions for further reading:

1. Chiha M, Samarasinghe S, Kabaker AS.


Oral Case Summary References/suggestions for further reading: 1. Chiha M, Samarasinghe S, Kabaker AS.

Oral Case Summary
Diagnosis: Thyroid Storm Case Summary: A 33-year-old female with a past medical history of celiac disease presents to the emergency department via emergency medical services with altered mental status.The patient's husband is at the bedside and provides further history.Her physical exam is remarkable for altered mental status, diaphoresis, palpable goiter, and an irregularly irregular cardiac rhythm.

yroid Storm Case Summary:
A 33-year-old female with a past medical history of celiac disease presents to the emergency depart

nt via e
ergency medical services with altered mental status.The patient's husband is at the bedside an

provides fur
her history.Her physical exam is remarkable for altered mental s

lpable goiter, and an irr
gularly irregular cardiac rhythm.


Order of Case:

The learner should start by assessing the patient's general appearance and ABCs.Vital signs should be obtained.With the patient's altered mental status, a point-of-care glucose should be ordered early in the case.A full history and physical exam should be performed.Labs and computed tomography (CT) of the head should be ordered

Order of Case:
The learner should start by assessing the patient's general appearance and ABCs.Vital signs should be obtained.With the patient's altered mental status, a point-of-care glucose should be ordered early in the case.A full history and physical exam should be performed.Labs and computed tomography (CT) of the head should be ordered.Sepsis will be on the differential, so treatment with broad-spectrum antibiotics should be initiated.The patient's clinical presentation will be consistent with thyroid storm, and the learner should start treatment.It is important that the learner specifies that they will not administer any iodine-containing products until at least one hour after the thionamides (propylthiouracil or methimazole).The learner should update the family about the patient's plan of care, and this patient should be admitted to the medical intensive care unit.

epsis will be o
the differential, so treatment with broad-spectrum antibiotics should be initiated.The patient's clinical presentation will be consistent with thyroid storm, and the learner should start treatment.It is important that the learner specifies that they will not administer any iodine-containing products until at least one hour after the thionamides (propylthiouracil or methimazole).The learner should update the family about the patient's plan of care, and this patient should be admitted to the medical intensive care unit.

Disposition: Admit to the intensive care unit.


Critical Actions:

1. Perform a complete history and physical exam.

2. Obtain a point-of-care blood glucose.

3. Order appropriate labs and imaging: complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis with culture, pregnancy test, urine toxicologic screen, acetaminophen level, et Disposition: Admit to the intensive care unit.

Critical Actions:
1. Perform a complete history and physical exam.
2. Obtain a point-of-care blood glucose.
3. Order appropriate labs and imaging: complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis with culture, pregnancy test, urine toxicologic screen, acetaminophen level, ethanol level, salicylate level, troponin, creatine kinase (CK), thyroid function studies, lactic acid, arterial blood gas (ABG), blood cultures, electrocardiogram (ECG), chest X-ray, and CT head.4. Begin broad-spectrum antibiotics.5. Start medications for treatment of thyroid storm with the proper sequence and timing.6. Admit the patient to the intensive care unit.

ion studies, lactic acid, a
terial blood gas (ABG), blood cultures, electrocardiogram (ECG), chest X-ray, and CT head.4. Begin broad-spectrum antibiotics.5. Start medications for treatment of thyroid storm with the proper sequence and timing.6. Admit the patient to the intensive care unit.


Historical Information


Chief Complaint: Confusion

History of present illness: A 33-year-old female presents to the emergency department via EMS with altered mental status.The patient is confused and cannot provide further history, but the patient's husband states that she had been complaining of some burning pain with urination for the past 3 days.She had been taking over-the-counter cranberry supplementation at home for these symptoms.The patient's husband went home

Chief Complaint: Confusion
History of present illness: A 33-year-old female presents to the emergency department via EMS with altered mental status.The patient is confused and cannot provide further history, but the patient's husband states that she had been complaining of some burning pain with urination for the past 3 days.She had been taking over-the-counter cranberry supplementation at home for these symptoms.The patient's husband went home to check on his wife after her coworkers called him stating that she did not show up to work that morning.He found her diaphoretic, laying on the couch.She was confused and could only tell her husband her name.He called EMS, who transported the patient to the emergency department for evaluation and treatment.

lled him stating that she did not show up to w
rk that morning.He found her diaphoretic, laying on the couch.She was confused and could only tell her husband her name.He called EMS, who transported the patient to the emergency department for evaluation and treatment.


Past


Primary survey:

• Airway: Patent and protected.

• Breathing: Tachypneic.B

Primary survey:
• Airway: Patent and protected.

Physical examination:
• General appearance: Laying on the stretcher, diaphoretic.

nce: Laying on the stretcher, diaphore
ic.



Medical history: Celiac disease Past Surgical history: Cesarean section three years ago Patient's Medications: Daily multivitamin, combined oral contraceptive Allergies: N Medical history: Celiac disease Past Surgical history: Cesarean section three years ago Patient's Medications: Daily multivitamin, combined oral contraceptive Allergies: No known drug allergies Social history: • Tobacco: Denies • Alcohol: Drinks one glass of wine two nights per week • Drug use: Denies Family history: No known medical problems run in the family Laying on the stretcher, diaphoretic.
known drug allergies Social history: • Tobacco: Denies • Alcohol: Drinks one glass of wine two nights per week • Drug use: Denies Family history: No known medical problems run in the family Laying on the stretcher, diaphoretic.


•

Head, eyes, ears, nose and throat (HEENT): o Head: N

t, nondistended.Suprapubic tendern
ss to palpation.No rebound tenderness or involuntary guarding.• GYN: No vaginal discharge or bleeding.Normal, closed cervix.No cervical motion tenderness.

Extremities: Normal range of motion of joints with no rigidity.• Neuro:
Agitated.Oriented to self only.Opens eyes to voice.Follows commands in all 4 extremities.Cranial nerves II-XII intact.5/5 strength and intact sensation to light touch in all 4 extremities.No clonus.Hyperreflexia.• Skin: Diaphoretic.No rashes.• Lymph No lymphadenopathy.• Psych: Unable to completely assess since patient is only able to state her name.Learner: _________________________________________ Standardized assessment form for oral boards cases.JETem ã Developed by: Megan Osborn, MD, MHPE; Shannon Toohe

PC1) Did not achieve Level 1 Recognizes abnormal vital signs Recognizes an unstable patient, requiring intervention Performs primary assessment Discerns data to formulate a diagnostic impression/plan Manages and prioritizes critical actions in a critically ill patient Reassesses after implementing a stabilizing intervention 2 Performance of focused history and physical (PC2) Did not achieve Level 1 Performs a reliable, comprehensive history and physical exam Performs and communicates a focused history and physical exam based on chief complaint and urgent issues Prioritizes essential components of history and physical exam given dynamic circumstances ORAL BOARDS ASSESSMENT
Standardized assessment form for oral boards cases.JETem ã Developed by: Megan Osborn, MD, MHPE; Shannon Toohey, MD; Alisa Wray, MD Ritter K, et al.Thyroid Storm.JETem 2020.5(4):O1-30.https://doi.org/10.21980/J8RW71 12

Did not achieve Level 1 Asks patient for drug allergies Selects an appropriate medication for therapeutic intervention, considering potential adverse effects Selects the most appropriate medication(s) and understands mechanism of action, effect, and potential side effects Considers and recognizes drug-drug interactions 6 Observation and reassessment (PC6) Did not achieve Level 1 Reevaluates patient at least one time during the case Reevaluates patient after most therapeutic interventions Consistently evaluates the effectiveness of therapies at appropriate intervals 7 Disposition (PC7) Did not achieve Level 1 Appropriately selects whether to admit or discharge the patient Appropriately selects whether to admit or discharge Involves the expertise of some of the appropriate specialists Educates the patient appropriately about their disposition Assigns patient to an appropriate level of care (ICU/Tele/Floor) Involves expertise of all appropriate specialists ORAL BOARDS ASSESSMENT
Standardized assessment form for oral boards cases.JETem ã Developed by: Megan Osborn, MD, MHPE; Shannon Toohey, MD; Alisa Wray, MD Ritter K, et al.Thyroid Storm.JETem 2020.5(4):O1-30.https://doi.org/10.21980/J8RW7113